ORAL SEDATION CONSENT (TRIAZOLAM)


Oral conscious sedation (Triazolam) utilizes the elective administration of an oral sedative medication during dental procedures to reduce the fear and anxiety related to the experience.

The purpose of this document is to ensure that you understand oral conscious sedation and consent to its use during your dental treatment. Please read each item carefully and initial next to the number after you have had the opportunity to discuss it with the attending Dentist, and your questions and concerns, if any, have been answered to your satisfaction.

Check box

1.

I understand that the purpose of oral conscious sedation is to more comfortably receive necessary dental treatment and that it has limitations and risks, and its absolute success cannot be guaranteed.

2.

I understand that oral conscious sedation is a drug induced state of reduced awareness and may decrease my ability to respond. The sedative will not put me to sleep and I will be capable of responding during the procedure. My ability to respond normally will return when the effects of the sedative wear off.

3.

I understand that the sedative prescribed will be in a pill form that I will take approximately 60 minutes before my scheduled appointment. The effects of this sedative can last for up to 12 hours following your dental visit. The duration of effectiveness may be different for each patient.

4.

Should the initial dosage of oral sedation not be sufficient to sedate to a comfortable level, I consent to the use of nitrous oxide in addition to the oral sedative. I also acknowledge I have had the opportunity to read/sign a separate (additional) consent form for the use of nitrous.

5.

I understand that the alternatives to oral conscious sedation are:
  1. No sedation: Treatment is performed using a local anesthetic, or not (should the use of anesthetic not be required. I.E for Hygiene), and the patient is fully aware of surrounding activity.
  2. Nitrous oxide sedation: Provides relaxation through inhalation of the gas, and the patient is still generally aware of surrounding activity. Its effects are rapidly reversed with the administration of oxygen.
  3. Intravenous sedation: The slow injection or drip of a sedative into to a vein.
  4. General anesthetic: Generally used in a hospital setting, it requires breathing to be supported and the patient has no awareness of his surroundings. (Not offered by this office)

6.

I have been informed that there are risks and limitations to all dental procedures. Additionally, with the use of oral sedation, the following risks are also present:
  1. Inadequate sedation with the initial dosage which may require undergoing the procedure without full sedation, or having to reschedule the procedure.
  2. Atypical reaction to the sedative drug which may require emergency medical attention and/or hospitalization such as, but not limited to: altered mental state, adverse physical reaction (I.E Dizziness and/or Nausea), allergic reaction or other unforeseen sicknesses.
  3. The inability to discuss treatment options during the procedure should the circumstance arise, that requires the Doctor to change the treatment plan. (I.E a filling that may be a root canal, or a root canal that is beyond restoration and requires extraction as an alternative)

7.

If, in the professional judgment of the attending Dentist, a change in treatment is indicated, I authorize him/her to proceed with it. I also understand that I have the right to designate another individual to discuss any changes of treatment with the Dentist.

8.

I have had the opportunity to discuss oral conscious sedation with the attending Dentist and have had my questions answered to my satisfaction.

9.

I understand and agree to follow all of the instructions given to me.

10.

I understand that if I am having any restorations completed, I am required to book a follow up visit within 24-48 hours to have my bite adjusted as an accurate bite cannot be recorded while I am sedated.

11.

I have informed the attending Dentist of and/or agree to the following:
  1. I am not pregnant or breast feeding
  2. I have disclosed all medications, supplements and recreational drugs that I currently take.
  3. I have disclosed any known allergies.
  4. I am of sound mental and physical ability to make the decision to use oral conscious sedation, and I understand what it is and what it is not.
  5. I will not consume alcohol within 24 hours of using oral conscious sedation.
  6. I understand that I will not be able to drive or operate machinery for 24 hours after completion of my treatment.
  7. I have made arrangements for transportation to and from my scheduled appointment, and for a responsible adult to stay with me for up to 12 hours following any appointments during which I have been sedated. (a taxi driver or similar escort service does NOT count as your ride)

12.

I acknowledge and assume responsibility for payment of the cost of sedation should it not be covered by my insurance policy for the procedure(s) I am having completed today.

I CONSENT TO THE USE OF ORAL CONSCIOUS SEDATION (TRIAZOLAM) TO BE USED IN CONJUNCTION WITH MY DENTAL TREATMENT - I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATIONS/LIMITATIONS PROVIDED. I ALSO STATE THAT I READ AND WRITE IN ENGLISH, IF THIS IS NOT THE CASE I CERTIFY THAT I HAVE HAD THE OPPORTUNITY TO HAVE THIS DOCUMENT TRANSLATED FOR ME.